Form Hhs-700 - Civil Rights Discrimination Complaint
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8Form Approved: OMB No. 0945-0002
Expiration Date: 04/30/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
OFFICE FOR CIVIL RIGHTS (OCR)
Civil Rights Discrimination Complaint
YOUR FIRST NAME
YOUR LAST NAME
HOME PHONE (Please include area code)
WORK PHONE (Please include area code)
STREET ADDRESS
CITY
STATE
ZIP
E-MAIL ADDRESS (If available)
Are you filing this complaint for someone else?
Yes
No
If Yes, whose civil rights do you believe were violated?
FIRST NAME
LAST NAME
I believe that I have been (or someone else has been) discriminated against on the basis of:
Race / Color / National Origin
Age
Religion / Conscience
Sex
Disability
Other (specify):
Who or what agency or organization do you believe discriminated against you (or someone else)?
PERSON / AGENCY / ORGANIZATION
STREET ADDRESS
CITY
STATE
ZIP
PHONE (Please include area code)
When do you believe that the occurred?
LIST DATE(S)
Describe briefly what happened. How and why do you believe you have been discriminated against? Please be as specific as
possible.
(Attach additional pages as needed)
Please sign and date this complaint. You do not need to sign if submitting this form by email because submission by email
represents your signature.
SIGNATURE
DATE
Filing a complaint with OCR is voluntary. However, without the information requested above, OCR may be unable to proceed
with your complaint. We collect this information under authority of Sections 1553 and 1557 of the Affordable Care Act, Title VI of
the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Church Amendments, the Coats-Snowe
Amendment, the Weldon Amendment, and other civil rights statutes. We will use the information you provide to determine if we
have jurisdiction and, if so, how we will process your complaint. Information submitted on this form is treated confidentially and is
protected under the provisions of the Privacy Act of 1974. Names or other identifying information about individuals are disclosed
when it is necessary for investigation of possible discrimination, for internal systems operations, or for routine uses, which
include disclosure of information outside the Department of Health and Human Services (HHS) for purposes associated with civil
rights compliance and as permitted by law. It is illegal for a recipient of Federal financial assistance from HHS to intimidate,
threaten, coerce, or discriminate or retaliate against you for filing this complaint or for taking any other action to enforce your
rights under Federal civil rights laws. You are not required to use this form. You also may write a letter or submit a complaint
electronically with the same information. To submit an electronic complaint, go to OCR’s web site at:
. To submit a complaint using alternative methods, see reverse page (page 2
of the complaint form).
HHS-700 (10/17) (FRONT)
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Parent category: Legal